1. A Comprehensive Training Strategy to Implement Self Management Support in a PCMH Kyle Knierim, MD Corey Lyon, DO, FAAFP Kimberly Breidenbach, MD, MPH Aimee Falardeau, MD

2. Disclosures None

3. Objectives Train staff and providers on the key elements of SMS, expressing the differences between SMS and patient education. Introduce SMS into clinic workflows. Utilize a strategy of direct observations to reinforce SMS skills

4. Group Activity Around the room are 4 questions Answer each question on the notecard –Leave the notecard at the station Later on we will ask volunteers to summarize and share the answers to each question

5. Question 1 How would you describe SMS in 1-2 sentences to your patient?

6. What is Self-Management Support? Assistance clinicians, staff, and care providers give patients to encourage daily decisions that improve health-related behaviors and clinical outcomes. Engaging patients in their own health care

7. What is Self-Management Support? Collaboration between the clinician and patient to acquire and practice skills needed to maintain and improve health Skill development –Health behavior change –Improve day-to-day control of their disease –Improve well-being

8. SMS ≠ Patient Education Patient education involves giving patients information (materials and instruction). Patient education does not engage the patient into acquiring and practicing skills and developing self-efficacy to manage their health issues.

9. Components of SMS Providing compassionate, patient-centered care Involving the whole care team in planning, carrying out, and following up patient visits Planning patient visits that focus on prevention and care management rather than critical or acute care Involving the patient in goal setting Providing customized education and skills training, using materials appropriate for different cultures and literacy levels Making referrals to community-based resources Following up with patients through email, phone, text messaging, or mailings to support them taking good care of themselves http://www.orau.gov/ahrq/sms_home.html

10. Show Me The Data! Diabetes Prevention Program – 60% risk reduction for developing Type 2 diabetes LOOK AHEAD (Action for Health in Diabetes) –Maintained weight loss (-6.15%) –Improved HgA1c –Improved lipids –Decrease in blood pressure Knowler, et al; Lancet; 2009. Wing, et al; Arch Intern Med. 2010.

11. Why is SMS Important? SMS improves health-related behaviors: –Improved dietary intake –Increased physical activity, –Improved medication adherence SMS improves clinical outcomes like A1C and BP SMS can result in improvement of quality of life indicators. Patients with effective SMS skills make better use of healthcare professionals’ time and have enhanced self-care

12. Our Setting: AF Williams Clinic Family Medicine Residency Teaching Clinic in an Urban/suburban setting Achieved Level 3 PCMH Recognition in 2011 18 residents, 22 medical providers (most part-time), 24 staff, 2 clinical pharmacy residents, 3 psychologists 12,500 active patients 27,000+ visits per year

13. Question 2 How were you trained in SMS?

14. Our Approach: Not just the providers… Goal for clinic wide training –Supporting patients isn’t just with the providers To move the clinic forward, you need to move the clinic forward as a whole A mixture of clinic wide training, and role specific training

15. Training the clinic Training included education about SMS –Role specific (while trying to define those roles…) –Participation in SMS varies depending on roles Also focus on “Patient Centeredness” education/training

16. Setting the Stage E-learning modules Clinic-wide meeting Epic (EMR) documentation strategy Time to Digest Context of patient centered communication Role-specific meetings Practice Makes Perfect Example videos Role play Just Do It! 360 ° Observations Targeted follow ups

17. E-learning Modules

19. Setting the Stage Local expert gave presentation at all-clinic meeting Mix of didactic presentation and group discussion

20. Epic Documentation Strategy

21. Question 3 Who is responsible for SMS in your clinic?

22. Time to Digest Put SMS into the context of patient centered communication –Special thanks to Larry Mautsch and his tools –https://catalyst.uw.edu/webq/survey/mkeen/14 2290https://catalyst.uw.edu/webq/survey/mkeen/14 2290 Staff and provider meetings devoted to the topic

23. Practice Makes Perfect Video examples of both a provider and an MA

24. Practice Makes Perfect Video examples of both a provider and an MA Role play

25. Just Do It! Permission given to everyone to try it out 360 ° Observations Periodic follow ups gradually ramped up pressure as comfort level increased

26. Outcomes

27. Training –38 people completed E-learning module –In-person session attendance 24 staff 24 faculty 15 residents

28. Outcomes 360 ° Observations –72 observations scheduled –56 were completed –Observed at least once MA’s: 10/11 (91%) Providers: 14/22 (64%) Residents: 12/21 (57%)

29. Percent of Patients With Diabetes with Patient Goals Set

31. NCQA Recertification Mock and Actual Chart Audit Data

32. NCQA SMS Items Mock Audit (July 2013) Real Audit (Nov 2013) Gives patient a written plan of care (3C-3)59% Assesses and addresses barriers when patient has not met treatment goals (3C-4) 24% Assesses patient understanding of medications (3D-4)29% Provides educational resources or refers at least 50% of patients to educational resources to assist in SM (4A-1) 47% Develops and documents SM plans and goals in collaboration with patients (4A-3) 35% Documents SM abilities (4A-4)24% Provides SM tools to record self-care results for patients (4A-5) 12%

33. NCQA SMS Items Mock Audit (July 2013) Real Audit (Nov 2013) Gives patient a written plan of care (3C-3)59%94% Assesses and addresses barriers when patient has not met treatment goals (3C-4) 24%75% Assesses patient understanding of medications (3D-4)29%38% Provides educational resources or refers at least 50% of patients to educational resources to assist in SM (4A-1) 47%100% Develops and documents SM plans and goals in collaboration with patients (4A-3) 35%88% Documents SM abilities (4A-4)24%88% Provides SM tools to record self-care results for patients (4A-5) 12%81%

34. Question 4 What are the challenges to implementing SMS in your clinic?

35. Learning Points Define roles better in the beginning –Figure out roles earlier in the process Involve patients earlier –PAC –Educate patients on SMS as well Introduction at check in? Handouts? Clinic signs? Even more support for providers –EMR tools, training, IT (goal setting tools), clinic workflows Line up SMS with other on-going activities

36. Barriers Hospital systems rules –Limits who can do what Breaking through traditional clinic model –Patient/provider in exam room IT support –Development of registries, processes to follow up on patient goals Teaching old dogs new tricks Herding cats……

37. Summary Providing SMS takes work Training the whole clinic can help Like most other things, there is always more to be done

38. Questions?

39. Contact kyle.knierim@ucdenver.edu